Pleno scenario B

bloc 7
dr. Swanny
Physiology Dept.

Respiration in High Altitude

Case of Ir. Cek nang, 56 years,
who went to resort of 3200
meters above sea level.

Overview of Gas Exchange in the Lungs

Adapted from: Costanzo, LS. Physiology, 1st ed.

1998.

Mathematical Description of Gas

Exchange
PaCO2 Partial pressure of CO2 in the arterial
blood.
PACO2 Partial pressure of CO2 in the alveolar
gas.
PaO2 Partial pressure of O2 in the arterial
blood.
PAO2 Partial pressure of O2 in the alveolar gas.

Mathematical Description of Gas

Exchange (cont)
Alveolar Ventilation Equation
Primarily describes the relationship
between PaCO2 and alveolar
ventilation.
Alveolar Gas Equation Primarily
describes the relationship between
PAO2, FIO2, and PaCO2.

Oxygen Transport
Oxygen is carried in the blood in 2
forms:
Dissolved O2 (~2% of total O2
content)
O2 bound to hemoglobin (~98% of
total O2 content)

Oxygen Transport (cont)

Total O2 content of blood (CaO2) =
Dissolved O2
+
O2 bound to
hemoglobin

Oxygen-Hemoglobin
Dissociation Curve at Rest

Hypoxia ( PaO2)
Respiratory failure manifesting as
hypoxia is known as oxygentation
failure.
Signs of oxygenation failure:
Tachypnea
Alkalemia (acidemia if concurrent
ventilatory failure)
Increased pulsus paradoxus
Cyanosis
Agitation Somnolence

Shifting the Curve

ALTITUDE MEDICINE

How high is high altitude?

High altitude: 1500-3000m above sea level
Very high altitude: 3000-5000m
Extreme altitude: above 5000m
Death zone: above 8000m

Why does high altitude

affect
us?
All the medical effects of high altitude are
caused by oxygen deprivation.
The reduction in oxygen is best described
by the fall in inspired partial pressure of
oxygen
These altitudes can have serious physical
effects on humans.
The three major areas that are affected
are:
mental performance
physical performance
quality of sleep

High Altitude Diseases

Altitude Sickness- Hypoxia
Low oxygen pressure
Ambient pressure and partial pressure of
oxygen decrease with altitude.
AMS- Acute Mountain Sickness
Monges Disease
Rarely occurs below 2500 m
Headache, drowsiness, general fatigue,
difficulty breathing during physical exertion,
nausea, loss of appetite.

Altitude Stressors
Hypoxia
Over 2000m
PO2 at 5000m half that of sea level

Cold
Drop 6.5 per 1000m

Aridity
Radiation

Hypoxic responses
Respiratory
rate

Cardiovascular
rate and stroke volume
Pulmonary vasoconstriction and cerebral
vasodilatation (increases PA pressure)

Hematology
red blood cell mass and plasma viscosity
O2 Hb dissociation curve shift to left to
increase affinity for O2 (so less delivered to
tissues)

Acclimatization
Acute hypoxic stress is poorly
tolerated but given time to adapt the
body can handle certain degrees of
hypoxia very well
How? Changes in ventilation, blood,
fluid balance, and cardiovascular
parameters.

Acclimatisation
Process by which people gradually adjust to
high altitude
Determines survival and performance at high
altitude
Series of physiological changes
O2 delivery
hypoxic tolerance +++
Acclimatization depends on
severity of the high-altitude hypoxic stress
rate of onset of the hypoxia

Ventilatory acclimatisation
Hypoxic ventilatory response = VE
Starts within the 1st few hours of exposure 1500m
Mechanism

O2 + H2O

Ascent to
altitude
Hypoxia
Decreased PCO2

Carotid body stimulation

Respiratory centres
stimulation
Increased ventilation

H2CO3

HCO3- + H+

Improved hypoxia

Adjustment of respiratory
alkalosis
alkaline bicarbonate excretion in the
urine
but slow process !
Progressive increase in the sensitivity of
the carotid bodies
After several hr to days at altitude
(interval of ventilatory acclimatization):
cerebrospinal fluid pH adjustment to the
respiratory alkalosis

Lung diffusion
Definition
Process by which O2 moves from the alveolar
gas into the pulmonary capillary blood, and
CO2 moves in the reverse direction
High altitude O2 diffusion, because
a lower driving pressure for O2 from the air
to the blood
a lower affinity of Hb for O2 on the steep
portion of the O2/Hb curve
and inadequate time for equilibration

V/Q heterogeneity

At rest

At high altitude
interstitial oedema
heterogeneity +++

O2
- Inhaled air is not evenly distributed to alveoli
- Composition of gases is not uniform
throughout lungs
- Different areas of the lungs have different
perfusion

Blood Acclimatization
Increase in EPO within 2 hours benefit in exercise tolerance only
with long term stays. Not important
for alt. Sickness
Increase 2,3-DPG (shifts
oxyhemoglobin diss curve R).
However resp alkalosis shifts curve L
so likely no net effect
If at altitude for a while, red cells
(some advise aspirin while at

Fluid Balance
Acclimatisation
Peripheral venous constriction
increased central volume
decreased ADH and aldosterone
diuresis
decreased plasma volume and
hyperosmolality.

Antidiuresis is sign of acute mountain

sickness

Cardiovascular
Acclimatisation
Increased HR and sympathetic tone
compensates for lower stroke volume
hypoxia pulmonary circulation
constriction
helpful for pneumonia, effusions etc
but not for global hypoxia
leads to pulmonary hypertension

Changes during sleep

Some people have trouble sleeping
above 2500m
Many have problems above 4500m
Periodic breathing may occur
Avoid sedatives and alcohol reduce
breathing further at night

When acclimatisation fails

Altitude syndromes
Acute mountain sickness (AMS): the leastthreatening and most common
potentially lethal
High altitude pulmonary oedema
form of altitude
High altitude cerebral oedema illness
All these syndromes have
several features in common
respond to descent or oxygen

Acute Mountain Sickness

Constellation of symptoms in context
of recent gain in altitude
Similar to a hangover

50% at 3500m
Most at 5000m

Altitude Pathophysiology
Hyperventilation
to compensate
for decreased
FiO2

Alkalosis

Episodic respiratory
arrests during sleep

Suppression of
breathing during
sleep

Altitude Pathophysiology
Vasodilation

Hypoxia

Increased
cerebral
blood flow

Increased
Capillary
Permeability

Cerebral
edema

Pulmonary
edema

Peripheral
edema

Increased
cold injury
risk

Altitude Sickness
Symptoms
Mild Acute Mountain Sickness

Headache
Malaise
Anorexia
Nausea, vomiting

Dizziness
Dyspnea on exertion
Dry cough
Decreased urine output

Any AMS symptoms are due to

altitude until proven otherwise

Precautions and
Prevention

Acclimatization- adapting to the

oxygen deprivation of high
altitude to some extent
Although acclimatization
ameliorates the hypoxia of high
altitude to some extent,
professionals still recommend
supplementary oxygen.

Precautions and
Prevention
Plenty of rest
Avoid alcohol
Avoid tobacco
Avoid marijuana
Stay hydrated
Avoid heavy meals

Hypoxia Treatment
Treat the underlying process
Increase FIO2 with supplemental
oxygen
Reposition the body
Secretion management
Bronchodilation
Diuresis
Increase mean lung volume
Reduce O2 requirement
Consider transfusion if [Hb] < 7.0

AMS - Treatment
Mild
Rest and stop
ascent
Descend if not
improved
after 24 hours
Drink fluids
Simple
analgesics

Moderate/Severe
Descend
100m
Acetazolamide
Dexamethason
e
Hyperbaric O2
(Gamow bag)

Thank you